Australia’s primary health care workforce — research informing policy

Kirsty A Douglas, Frith K Rayner, Laurann E Yen, Robert W Wells, Nicholas J Glasgow and John S Humphreys
Med J Aust 2009; 191 (2): 81-84. || doi: 10.5694/j.1326-5377.2009.tb02698.x
Published online: 20 July 2009

A strong primary health care system has been shown to improve patient health outcomes, reduce costs, reduce health inequities and increase patient satisfaction regarding their care.1 To achieve these goals in Australia, the primary health care workforce will need to be adequate, sustainable and effective. Currently, however, Australia’s primary health care workforce is facing significant challenges in supply, distribution, changing demands and role delineation.1-4 In 2008, the Australian Minister for Health and Ageing established the National Health and Hospitals Reform Commission (NHHRC) to report on how best to approach long-term reform for the Australian health care system to effectively meet these challenges.5 During NHHRC consultations, the need for a synthesis of Australian evidence relating to primary health care workforce and its implications for policy options became apparent. In this article, we discuss policy options suggested to the NHHRC by the Australian Primary Health Care Research Institute (APHCRI),6 based on the Primary Health Care Workforce Roundtable held in Canberra on 29 August 2008.

The APHCRI was established in 2003 to provide national leadership in improving the quality and effectiveness of primary health care through the conduct of high-quality, priority-driven research, and in supporting and promoting best practice. It has an explicit commitment to improving the translation of research into policy.

In 2006, the APHCRI Research Advisory Board commissioned work to examine Australian and overseas evidence related to increasing numbers of general practitioners, optimising the existing primary health care workforce, and understanding the place of generalism in primary health care. Funding for research grants was allocated via a competitive peer-reviewed process. All projects were required to demonstrate their relevance and value to current and emerging issues in Australian health policy, and articulate potential policy options arising from the research in the final reports. The nine successful projects (Box 1) were systematic reviews that used a narrative approach.7

In 2008, the APHCRI was asked by the NHHRC Commissioners for policy options drawn from a synthesis of available evidence on the primary health care workforce. The 2006 findings from the APHCRI projects were presented to Australian primary health care experts at the 2008 Primary Health Care Workforce Roundtable. Participants were encouraged to draw on their individual expertise and practical experience, as well as recent APHCRI and overseas research, to build a vision for the future of the primary health care workforce in Australia.

Broader issues, such as funding and models of care, were discussed only with respect to their potential impact on primary health care workforce profile and capacity. The recommendations that arose focus mainly on the general practice component of the wider primary health care workforce (GPs and primary health care nurses), as this was where most of the evidence lay. The submission to the NHHRC was formulated from the debate, discussion and policy options that arose at the meeting (Box 2).

Expanding the primary health care workforce

Increasing primary health care workforce numbers in Australia requires a broad range of strategies. Nurses in general practice have received much attention as a potential, or necessary, part of the primary health care workforce solution. There are particular roles that primary health care nurses can successfully adopt — proactive patient follow-up, general patient consultation and support, and care planning and goal setting.11 Research on community nursing affirms that nurses working in primary health care can “help address workforce shortages, improve access to health care and contribute to the management of chronic conditions and illness prevention”, leading to suggestions that the role of practice nurses should be expanded and that this profession should be given a clear career pathway and clear training.12 Delineating the role of the primary health care nurse (or general practice nurse) may help attract nurses to the sector in the face of declining overall workforce numbers.

The number of general practice nurses in Australia increased by 59% during the period 2005–2007.13 Most practice nurses join the profession via hospital work, and their training in the tertiary environment is not always compatible with work in the primary health care sector. Despite this, there is no nationally agreed set of competencies required to enter primary health care nursing, no formalised postgraduate training or accreditation in primary health care nursing, and minimal exposure to primary health care nursing in undergraduate courses. These issues need to be addressed.

The research evidence around potentially broader roles for nurses in primary health care and chronic disease management was uncontested by participants of the Roundtable. However, they concluded that the Medicare Benefits Schedule (MBS) is too complex and rigid to allow the best use of nurses’ skills. Nurses in general practice are funded for particular actions only, thereby significantly limiting the ability of practices to maximise and individualise their various talents. The participants noted that, even with targeted incentive payments, the fee-for-service system has difficulty supporting GPs and other team members to: allocate time for comprehensive management of chronic and complex conditions, conduct health promotion and illness prevention activities, use team care approaches in specific patient groups, and allow cross-sectoral planning for a local population. A systematic review and international comparison of the impact of different funding initiatives on access to multidisciplinary primary health care concluded that alternative funding arrangements, such as capitation and contracting, could be more widely adopted in Australia to enhance access to care for vulnerable population groups without fundamentally changing the overall fee-for-service financial arrangements.14

Recommendations for a sustainable primary health care workforce

Following discussion of these and other issues, several key recommendations for a sustainable primary health care workforce emerged around the themes of funding and financial arrangements, workforce education and training, and interprofessional organisation and teamwork.

In making these specific recommendations to the NHHRC, the APHCRI is cognisant of the timetable for action that is required. Simplifying the MBS could be achieved quickly, and would have an immediate effect. Other recommendations — namely those relating to the funding of medical and nursing education in the primary health care sector, the development of career structure and training pathways, and the development of functional primary health care teams — need to be initiated quickly, even though their full benefit will not be realised for several years. A clear implementation strategy is important to ensure that action is taken, monitored, and evaluated using appropriate performance indicators. Also, the implementation strategy should include constant “feedback loops” from the evaluation to inform progressive policy improvement.

This article focuses specifically on workforce issues, but it is clear that Australia’s ability to ensure an adequate supply of an appropriately trained primary health care workforce requires broad systematic changes that tackle underlying issues of funding, financial arrangements, service organisation, role delineation and career pathways, and education and training paradigms. Introducing a blended funding model for primary health care may be politically challenging, but mounting evidence suggests that it is worth developing and trialling. In the absence of attention to broader issues, specific workforce reform alone may founder and not achieve intended goals.

2 Methods used by the APHCRI to produce a submission to the NHHRC on policy options for the primary health care workforce from the 2008 Primary Health Care Workforce Roundtable

Participants of the meeting

Participants included primary health care researchers, policymakers, practising clinicians (general practitioners and nurses) and students. All were invited as individual experts, rather than as representatives of peak workforce organisations.

Background articles

Participants were provided with two papers summarising major findings of APHCRI-commissioned projects8,9 and links to the final reports from each project.

Meeting structure

The meeting was structured around three questions:

Three brief presentations summarised the APHCRI evidence, described what will be different in health in 2020, and provided information on the current general practice workforce. Participants were asked to consider what the key features of a functional primary health care workforce would be in 2020 and, given that vision, how it could be achieved via currently available or newly created mechanisms.

Throughout a facilitated discussion, participants were encouraged to develop practical policy options by considering the evidence and the context in which the policy would apply. Potential policies were discussed in terms of effectiveness (will it work?), appropriateness (should we do it?) and implementation (how would we make it work?).10

The discussion was recorded, and notes were taken by two staff members.

Formulation of submission to NHHRC

After the meeting, we summarised the debate, discussion and policy options that arose at the meeting, drafted a submission to the NHHRC, and circulated the draft to all participants for amendments and comments. Suggestions were adopted and the final document was distributed to participants before being sent to the NHHRC. All participants were acknowledged in the final document.

APHCRI = Australian Primary Health Care Research Institute.
NHHRC = National Health and Hospitals Reform Commission.

  • Kirsty A Douglas1
  • Frith K Rayner2
  • Laurann E Yen1
  • Robert W Wells1,3
  • Nicholas J Glasgow4
  • John S Humphreys5

  • 1 Australian Primary Health Care Research Institute, Australian National University, Canberra, ACT.
  • 2 Australian General Practice Network, Canberra, ACT.
  • 3 Menzies Centre for Health Policy, Australian National University, Canberra, ACT.
  • 4 Australian National University Medical School, Australian National University, Canberra, ACT.
  • 5 Faculty of Medicine, Nursing and Health Sciences, Monash University, Bendigo, VIC.



We thank the other participants of the APHCRI Roundtable, who contributed to the submission to the NHHRC: Ms Belinda Caldwell, Dr Paul Grinzi, Dr Mukesh Haikerwal, Professor Mark Harris, Dr Ross Maxwell, Dr Lucio Naccarella, Dr Rhian Parker, Dr Jenny Reath, Dr Tanya Robertson, Ms Raquelle Semrani, Associate Professor Beverly Sibthorpe, Associate Professor Jill Thistlethwaite and Professor Nicholas Zwar.

Competing interests:

Kirsty Douglas is an employee of ACT Health on secondment to the APHCRI. Nicholas Glasgow was the Foundation Director of the APHCRI until January 2008. John Humphreys was recompensed for airfares to attend the Primary Health Care Workforce Roundtable by the APHCRI, and received a fee for preparing for and facilitating the meeting.


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